CASE20230516_001

Percutaneous Closure of Paravalvular Leak From a Rocking Mitral Valve in a 66-Year-Old Woman at High Surgical Risk

By Huijin Lee, Jeehoon Kang
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Presenter

Huijin Lee

Authors

Huijin Lee1, Jeehoon Kang1

Affiliation

Seoul National University Hospital, Korea (Republic of)1
Other Interventions - Other Interventions

Percutaneous Closure of Paravalvular Leak From a Rocking Mitral Valve in a 66-Year-Old Woman at High Surgical Risk

Huijin Lee1, Jeehoon Kang1

Seoul National University Hospital, Korea (Republic of)1

Clinical Information

Relevant Clinical History and Physical Exam

In May 2023, a 66-year-old woman was referred for New York Heart Association functional class III fatigue and exertional dyspnea due to severe paravalvular leakage (PVL) of her prosthetic mitral valve (MV). Her medical history included scarlet fever and rheumatic heart disease, with six previous open heart surgeries (OHS) from 1986. Especially the trido-mitral valve replacement (MVR) performed to correct the mitral annular disruption in 2000.

Relevant Test Results Prior to Catheterization

In echocardiography, a Dshaped left ventricular (LV) cavity with preserved LV ejection fraction and adilated right ventricular (RV) cavity with depressed RV systolic function wereconfirmed. Also, diffuse severe PVL of the prosthetic MV with rocking motionwas shown at 5-8 o’clock in Surgeon’s view.

Relevant Catheterization Findings

In cardiaccatheterization, group 2 pulmonary hypertension was also combined with adecreased cardiac index (C.I.) (LV end diastolic pressure 33 mmHg, mean pulmonaryartery pressure 49 mmHg, C.I. 1.89). Considering the high peri-operative (OP)risk and severe intra-thoracic adhesion, we planned percutaneous PVL closure.

Interventional Management

Procedural Step

The patient wasplaced under general anesthesia. After gaining access through the right femoralvein, we performed a transseptal puncture. Under transesophagealechocardiography (TEE) guidance, we advanced a guidewire transeptally throughthe area of the PVL into the ascending aorta. Then, successfully, we placed a12x9-mm vascular plug in the PVL area. However, right after the firstdeployment, mechanical ventilator pressure suddenly increased, and a hugeamount of fresh bloody secretion was suctioned every 5 minutes. The activatedclotting time was 239 seconds. We performed a second deployment of a 9x10mm-sizedvascular plug quickly and quit the procedure by administering Protamine 20mg.Unfortunately, TEE showed similar amounts of PVL flow at the prosthetic MV.After theprocedure, large amounts of bleeding were confirmed in the left pulmonaryartery through a computerized tomography scan. The patient was positioned in a"left-down position" under complete paralysis and deep sedation.Using bronchoscopy, aspirated blood was toileted. After that, the patientinhaled nitric oxide gas to decrease pulmonary artery pressure. After 7 days ofICU care, the patient stabilized enough to transfer to the general ward withbilevel positive airway pressure.

Case Summary

We tried toclose a severe PVL with a rocking mitral prosthesis in an elderly patient whohad a history of six previous OHS. We planned to perform the procedure becausewe judged that it is less invasive than OHS and has a lower peri-proceduralrisk. In this case, we could know that the peri-procedural risk is not lowerthan the peri-OP risk. Underestimating the peri-procedural riskdue to the less-invasiveness of the procedure should be thought of as anotherrisk factor of the procedure.